Breast Reduction | Cosmetics & Makeup | Breast, Reduction, Patient, Procedure, Surgery

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Cosmetic Surgery

Breast Reduction

Another common plastic surgery procedure that yields consistently excellent results is breast reduction. Often, a woman whose breasts are very large experiences both physical and emotional discomfort, and is an excellent candidate for breast reduction surgery.

Women with naturally large breasts can be bothered with severe neck pain, back pain, shoulder strap tenderness, indentations from the bra straps, and the psychological effects of having such large breasts. Girls who develop large breasts at a young age are often teased and may become the object of jokes. Breast reduction can help these women, both physically and emotionally.

Breast reduction procedures, available for many years, are becoming more and more refined. Prior to this operation, it is very important that a patient not smoke, as there can be problems with poor wound healing and poor blood supply to the nipple areolar complex. A patient who does smoke must stop at least two weeks ahead of time and not resume for at least two weeks after surgery.

Breast Reduction Image 1

Courtesy of Kimberly A. Henry, M.D.

Figure 13-1. Before breast reduction, the patient was a size 38DD and complained of severe back and neck problems.

Breast Reduction Image 2

Figure 13-1. After breast reduction, she is now down to a size 38C and much more comfortable.

The most common type of reduction is the McKissick breast reduction, which involves removing breast tissue from the right and left sides of each breast and repositioning the nipple, which remains attached to breast tissue throughout the procedure. After surgery, a patient will have an incision around the nipple areolar complex and underneath the breast. (See Fig. 13-1.)

WILL MY INSURANCE COVER THIS?

Breast reduction is frequently covered by insurance companies, and after a consultation, the surgeon will obtain pictures and send them to the insurance company with an explanatory letter to obtain preauthorization for the procedure. If the patient is significantly debilitated as a result of large breasts, the plastic surgeon will express those concerns when presenting the case to the carrier. Although some insurance companies are becoming stricter about authorizing breast reduction, it is a type of surgery that is usually medically necessary for the well-being of the patient. Often, the company asks the patient to lose weight or to attend physical therapy sessions prior to authorizing the surgery.

The goals and expectations of both patient and doctor should be discussed in detail. One of the main concerns will be the patient’s ability to accept the scars that normally result from this procedure. Most women are so happy at the thought of improved body contours and relief from neck and back pain that they don’t focus on or mind the scars.



Figure 13-2. Breast assymetry is common to many women.	Figure 13-2. Breast reduction improves the symmetry and size. These incisions are typical of breast reduction procedures.

Courtesy of Kimberly A. Henry, M.D

THE PROCEDURE

I usually have my patients check into the hospital the morning of the surgery, usually between 6:00 and 6:30 a.m., as these surgeries are often scheduled at 8:00 a.m. I meet them in the holding area before the operation and draw some markings on the breasts with a purple surgical marking pen. The markings remain permanent on the body throughout surgery and for a few days postoperatively. Then these markings quickly fade.

THE PROCEDURE continued...

Symmetry is a critical aspect of this procedure. Frequently, a patient will exhibit asymmetry between the two sides, with one breast being larger than the other. If the left breast is a bit larger than the right, this is taken into consideration, and the procedure is modified appropriately (see Fig. 13-2). The nipples will be repositioned. (The normal nipple position from the point at the base of the neck is anywhere from nineteen to twenty-three centimeters, depending on the height of the patient.) If breasts are ptotic, or droopy, the nipple has to be repositioned to a higher point. The surgical markings done before the operation are probably the most aesthetically critical part of the entire operation. When the markings are done correctly, the patient will have beautiful results.

Following this, the patient is brought into the operating room, placed on the operating table, and given general anesthesia. During the operation, the patient is positioned symmetrically on the operating room table. I will often have a second plastic surgeon work with me during the operation in order to save time on anesthesia and to allow for improved symmetry between the right and left breasts. We usually operate simultaneously with two teams of nurses assisting us.

Following the breast reduction, the incisions are closed with sutures. I usually use dissolving sutures that are buried underneath the skin and dissolve on their own (a subcuticular closure), although I will occasionally use some sutures that have to be removed in one to two weeks following the procedure. Most patients prefer sutures that dissolve because they leave very few stitch marks.

In addition, I use drains that are removed the following day; however, some plastic surgeons do not use drains. This decision depends on a surgeon’s experience and personal preference.

I also use a breast wrap consisting of gauze wrapping that looks like a mummy wrap around the breast area and is changed daily for about two weeks. Each surgeon has his or her own preferences for postsurgery dressing, some using gauze and some suggesting the use of a bra immediately after surgery. We recommend avoiding an underwire bra, as this can cause unnecessary irritation to the incision line. We also recommend a support bra, with support needed most on the outside of the breast, near the arm, as breast tissue will continue to mold and form for the next four to six months.

The final shape of the breast is not evident for up to six to eight months postoperatively. Following the surgery, the incisions will be red and noticeable for up to one year.

COMPLICATIONS

The main complications from this kind of procedure are bleeding and infection. On occasion, one of the patient’s breasts might become more swollen than the other. This is a sign of a hematoma, a fluid collection, or bleeding. If this occurs, it is necessary to take the patient back to the operating room where general anesthesia is once again administered. The previous incisions are reopened, and any hematoma can be evacuated and bleeding controlled. The incisions are reclosed, and in most cases, the patient’s healing process progresses normally.

COMPLICATIONS continued...

A second concern is infection. The patient is given intravenous antibiotics before, during, and after the procedure to allow as much protection as possible. Breast infections are uncommon, but if they do occur, it’s very important that your plastic surgeon immediately puts you on a course of IV or oral antibiotics. Signs of infection include redness, tenderness, fever or chills, or purulent drainage coming from the incision line.

At about four to six weeks, the incisions look the best that they will look. At about eight to ten weeks, they are very noticeable: quite red, lumpy, and bumpy. Do not despair. There are ways to calm the scar, such as applying vitamin E oil to the incision line. It’s as easy as taking a small capsule of vitamin E, puncturing it with a sterile pin, draining the oil onto the incision line, and rubbing it gently onto the scar. In addition, a new technique using Silastic sheeting (which has been around for approximately four or five years) compresses the area and will help minimize the final scar. If you have significant scarring, the third option is steroid injections; however, they occasionally can cause widening of the scar.

Immediately after the procedure, most patients realize that their back pain/neck pain is alleviated. They no longer have the feeling of “heaviness.” After a breast reduction, a patient will often look at her stomach and say, “Oh my goodness, I could never see my stomach like this before!”

Sometimes, breast reduction patients are also candidates for an abdominoplasty, or tummy tuck. Occasionally, we combine the two procedures for patients who are in excellent health. This might mean that the patient will have to spend an extra night in the hospital, as opposed to staying only one night or going home the day of the procedure. When an abdominoplasty—a major procedure in itself—is combined with a breast reduction, it is important that the patient be monitored closely, and that the hospital staff is readily available for her comfort.

Scrupulously heeding the surgeon’s instructions about ambulation or movement following the procedure is crucial, even critical. Patients must limit activity for four to six weeks, and no heavy lifting must be attempted. If the patient has small children, she cannot lift them, and must relegate this duty to someone else. A young patient who is considering this procedure is sometimes told to postpone the surgery (unless the breasts are quite large) until after childbirth. There are some patients who are so large by the age of fifteen or so that a breast reduction must be done to prevent further back problems, however.

For a few days after surgery, the patient may feel some discomfort when moving or walking. Medication and rest will alleviate the pain. Bandages or dressings will be removed a day or two after surgery, but it is necessary to wear the surgical bra continually for several weeks until the swelling and bruising have dissipated. Stitches are removed in one to three weeks. It is not unusual for the woman to experience sharp pains in her breast area, a loss of sensation in the nipples, and general soreness, but this will greatly improve with time. The patient can usually return to work in about two to four weeks.

It may be necessary to perform two or three breast reductions on patients if the breasts continue to grow after surgery is completed. I remember one young woman who was ready to go off to college, had a breast reduction, and then returned a year later requiring another breast reduction because her breasts continued to grow following the surgery. Although this is rare, each patient must be told that there is always a possibility that the breast reduction procedure may have to be done again in the future. (See Table 13-1.)

DETECTING BREAST CANCER DURING A BREAST REDUCTION

It’s very important to obtain a preoperative mammogram that can detect early signs of breast cancer if a patient is over the age of thirty-five and has a family history of breast cancer. A breast exam is extremely important before any type of breast surgery as well. We can spot breast cancers during the breast reduction procedure in approximately 2 to 7 percent of patients undergoing breast reduction. The specimen, as in all cases, is sent for pathologic examination to be evaluated by a pathologist.

DETECTING BREAST CANCER DURING A BREAST REDUCTION continued...

If breast cancer is suspected or found, a mastectomy will not be done in the operating room at the time you are undergoing breast reduction. Your plastic surgeon will consult with you following the procedure and will let you know that suspicious tissue discovered during the breast reduction was evaluated by the pathologist, and it was found to be cancerous. The plastic surgeon will then recommend consultation with a general surgeon, and other options for breast surgery will be discussed in detail.

Table 13-1.

Breast Reduction

Recovery Time	Risk Factor	Pain Factor	Cost Factor

Initial: 10 days Complete: 3–4 weeks	Minimal if the patient is in good health Not recommended for patients who smoke	Most patients go home on oral medication the day after surgery	Most insurance companies foot the bill, but with HMOs tightening the reins, most patients are now having to pay anywhere from $4,500–$8,700

THE LATEST TECHNIQUES

There are other procedures currently utilized for breast reduction. Liposuction of the breast tissue, initially presented by Madeline Lejour, is one. This is fine for fatty breasts with minimal ptosis, or drooping, and sagging skin. If you have a significant amount of ptosis, however, you may need to have skin resection and occasionally return for skin removal. Two other techniques, developed by European surgeons Lejour and Benelli, call for smaller incisions. Dr. Benelli suggests using a circular incision around the areola, removing the excess breast tissue but leaving a cone of remaining breast tissue. The result is aesthetically pleasing. But a plastic surgeon has to be well versed in this technique in order to achieve a reasonable outcome because it can cause much scarring and asymmetrical nipple areolar complexes. Consulting with a plastic surgeon familiar in these techniques will help you decide what would be most appropriate for your type of breasts.

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